Every finding on record at The Haven of Arcola

Based on observation, interview and record review the facility failed to protect the resident's right to be free from physical and sexual abuse by other residents. The failure affects four of four residents (R2, R3, R4, R5) reviewed for abuse on a sample list of seven. Findings include: 1.) The facility's Final Incident Report dated 9/4/25 at 8:35AM sent to Illinois Department of Public Health reported an incident involving R4 and R5. The report states R4 was observed by staff on 8/30/25 at 3:50 PM touching R5 breast. R4's Medical Record documents R4 has diagnoses of schizoaffective disorder and cardiorespiratory condition. R4's Minimum Data Set (MDS) dated [DATE] documents R4 is cognitively intact and ambulatory with supervision. R4's care plan dated 11/13/25 documents R4's behaviors of being aggressive and making inappropriate statements to others. R5's Medical Record documents R5 has diagnoses of Severe Dementia without Behaviors, Major Depressive Disorder and Dysphagia Oral Phase. R5's MDS dated [DATE] documents R5 is severely impaired cognitively and ambulatory with supervision. R5's Care Plan dated 11/13/25 documents R5 exhibits behavior difficulties which include restlessness, anxiety, agitation, pacing and wandering. V16, CNA (Certified Nursing Aide) stated in interview on 11/18/25 at 2:23 pm, Yes, I did witness the incident with (R4) and (R5). I was coming around the corner and (R5) was standing at the first table in the dining room and (R4) was standing behind (R5) and was squeezing (R5's) left breast. (R5) was just standing there. (R4) was separated from (R5) and (R4) stated 'Leave me alone it makes me (aroused) squeezing her breast.' Yes, (R4) knew what he was doing. V17, CNA stated on11/18/25 at 2:27PM I did not witness the incident between (R4) and (R5) but couple of days before the incident I was taking (R4's) vital signs and (R4) stated to me 'Let me see your (breasts).' I reported the incident to the charge nurse that night. V1, Administrator stated on 11/18/25 at 3:00 PM, Due to the incident we moved R5 to the (other unit). 2.) The facility's State of Illinois Illinois Department of Public Health Long-Term Care Facility & IID -Serious Injury Incident Report dated 10/23/25 at 4:10 PM documents on 10/16/25 at 2:20 PM R2 open handed smacked R3 on R3's right upper arm. R2 stated R2 acted in retaliation claiming that R3 hit R2 first, however witnesses did not support that R3 hit R2. V8 Certified Nursing Assistant's (CNA) written Witness Statement dated 10/16/25 documents V8 was coming out of the CNA room and R3 grabbed onto the armrest of R2's wheelchair and R2 started smacking R3's arm. V8 immediately separated R2 and R3. The typed interview with R2 dated 10/16/25 documents the incident occurred on R2's hallway a little past R2's doorway. The interview documents R2 saw R3 coming down the hallway and as they passed each other R3 smacked R2 on the hand, so R2 smacked R3 back. R2's Minimum Data Set (MDS) dated [DATE] documents R2 as cognitively intact. R2's active Care Plan documents a problem dated 9/26/25 R2 that R2 is suspicious and paranoid of others entering her room without permission. This care plan includes a problem dated 2/11/25 that R2 has behaviors related to bipolar disorder, becomes anxious with agitation, has verbal outbursts, yelling and demanding of others, makes hateful/inappropriate comments, and mocking others. R3's MDS dated [DATE] documents R3 has short and long term memory impairment and is moderately impaired with cognitive skills for daily decision making. R3's active Care Plan documents R3's diagnoses include Dementia and Paranoid Schizophrenia, and a problem dated 7/25/25 that R3 wanders the hallways, violates the personal space of others, does not comprehend social limits and may be combative with staff. On 11/17/25 at 1:10 PM R2 was in her wheelchair in her room. There was a mesh barrier across R2's doorway with a stop sign that said, Do Not Enter. R2 stated R3 gets in people's rooms and sleeps in their beds and the facility hasn't done much about it. R2 stated there was one time that R3 got physical with R2 on an unidentified date. R3 tried to go into R2's room, R3 banged on my (R2's) arm, so I (R2) banged her (R3) back in the arm. On 11/17/25 at 9:36 AM R3 was sitting in the recliner in R3's room. R3 responded to name only but did not respond to any questions. On 11/17/25 at 1:27 PM V8 CNA confirmed V8 witnessed R2's/R3's altercation on 10/16/25. V8 stated the following: The incident happened between 2:00 PM and 2:30 PM. V8 witnessed R2 coming down the hallway from R2's room towards the nurse's station. R2 was in the middle of the hallway and R3 came up behind R2. R2 does not like people R2's personal space and R3 wanders and likes to go into other resident rooms and lay in their beds. R2 may have thought R3 was in R2's room. As R3 wheeled passed on the right side of R2, between the railing and R2, R3 grabbed the arm rest of R2's wheelchair to propel herself. R2 got upset, yelled at R3 and slapped R3 in the right hand three times reprimanding R3 like you would a child. R2's hit was intentional. R3 did not seem fazed or affected by R2. V8 told R2 that R2 should have waited since V8 was coming to assist R2. R2 swears that R3 hit R2 first, but V8 did not see R3 hit R2. V8 stated R3 may have accidentally bumped R2 when R3 grabbed R2's arm rest. R2 is with it, knows staff, and is alert/oriented to person, place, time and situation. R3 is confused and in her (R3's) own world.

Based on observation, interview, and record review the facility failed to implement care planned interventions for dementia related wandering behavior for one of four residents (R3) reviewed for abuse in the sample list of seven. Findings include:The facility's undated Abuse Prevention Policy documents Resident Assessment: As part of the resident's life history on the admission assessment, comprehensive care plan, and MDS (Minimum Data Set) assessments, staff will identify residents with increased vulnerability for abuse, neglect, exploitation, mistreatment, history of trauma or misappropriation of resident property, who have needs, triggers and behaviors that might lead to conflict. Through the care planning process, staff will identify any problems, goals, and approaches, which would reduce the chances of abuse, neglect, exploitation, mistreatment or misappropriation of resident property for these residents. Staff will continue to monitor the goals and approaches on a regular basis and update as necessary.The facility's State of Illinois Illinois Department of Public Health Long-Term Care Facility & IID -Serious Injury Incident Report dated 10/23/25 at 4:10 PM documents on 10/16/25 at 2:20 PM R2 open handed smacked R3 on R3's right upper arm. R2 stated R2 acted in retaliation claiming that R3 hit R2 first, however witnesses did not support that R3 hit R2. V8 Certified Nursing Assistant (CNA) written Witness Statement dated 10/16/25 documents V8 was coming out of the CNA room and R3 grabbed onto the armrest of R2's wheelchair and R2 started smacking R3's arm. V8 immediately separated R2 and R3. R3's MDS dated [DATE] documents R3 has short and long term memory impairment, is moderately impaired with cognitive skills for daily decision making and wanders. R3's active care plan documents R3's diagnoses include Dementia and Paranoid Schizophrenia, and a problem dated 10/25/23 that R3 wanders the hallways, into other resident rooms and gets into unoccupied beds. Interventions include to provide structured activities such as toileting, walking inside and outside, and reorientation strategies including signs, pictures and memory boxes.On 11/17/25 at 9:36 AM R3 was sitting in the recliner in R3's room. R3 responded to name only but did not respond to any questions. There were no pictures, memory boxes, or signs in R3's room or near the outside of R3's doorway to help R3 identify R3's room. There was only a standard name plate that is used for all residents, with R3's first initial and last name located near R3's doorway. On 11/17/25 at 11:55 AM V14 CNA stated R3 wanders and goes into other resident rooms. V14 stated we try to redirect R3 and R3 is also on 15-minute visual checks. V14 stated R3 relaxes in R3's recliner and enjoys watching television. V14 stated R3's name is outside R3's room door. V14 confirmed this is the same for all residents and lists first initial only. V14 went to R3's room and confirmed there are no pictures, shadow boxes, or signs to identify R3's room. V14 stated signs have been used on room doors to help other residents identify their rooms, but this has not been done for R3. On 11/17/25 at 1:27 PM V8 CNA confirmed V8 witnessed R2's/R3's altercation on 10/16/25. V8 stated the incident happened between 2:00 PM and 2:30 PM. R2 does not like people in R2's personal space and R3 wanders and likes to go into other resident rooms and lay in their beds. R2 may have thought R3 was in R2's room. As R3 wheeled passed on the right side of R2, between the railing and R2, R3 grabbed the arm rest of R2's wheelchair to propel herself. R2 got upset, yelled at R3 and slapped R3 in the right hand three times reprimanding R3 like you would a child. R3 had room changes over the last year and since then R3's wandering has been worse. R3 does recognize things in her room, likes her jewelry and bedding. V8 was asked if any pictures or signs had been used to help R3 identify her room. V8 stated that is a good idea, that might help R3 recognize R3's room. V8 confirmed pictures and signs had not been used.

Based on interview and record review the facility failed to provide a 30-day notice for an involuntary discharge for one of one resident (R1) reviewed for involuntary discharge in the sample list of seven.Findings includeThe facility's Immediate/Emergency Transfer and Discharge Policy dated September 2016 states To assure resident transfers and discharges will be conducted in accordance with residents' rights, physician's orders, and in such a manner as to maintain continuity of care for the resident.The Physician Order Sheet dated November 2025 documents R1 has the following diagnoses: Schizoaffective Disorder, Varicella without complications and Drug Induced Subacute Dyskinesia.R1's Minimum Data Set (MDS) assessment dated [DATE] documents, BIMs (Brief Interview for Mental Status) of 15, cognitively intact. The Facility Incident Report Final Report dated 11/15/25 documents R1 exited the building on 11/10/25 at 5:10 AM through the Southwest exit door and was found in a field about three blocks from the facility at 6:15 am. EMS arrived and transported R1 to the Emergency Department at the local hospital where R1 was diagnosed with hypothermia.The Progress Note dated 11/12/25 at 5:15 PM documents V9, Social Service Designee and V1 Administrator delivered involuntary discharge papers to R1 while at the hospital.V24, Brother of R1 stated on 11/15/25 at 10:52 AM Yes I am the half brother of (R1) and (R1) can barely talk he has a speech problem. I asked him what happened and he won't tell me anything. I would call the facility and talk with him on the phone, and (R1) has been at the same facility for over 20 years.V1, Administrator stated in interview on 11/15/25 at 2:30 PM, Yes (R1) was delivered involuntary discharge papers because we are not a locked unit and (R1) needs locked doors to keep him from exiting on his own. I told the hospital the facility would take him back as a resident if they would adjust his medication so (R1) would not want to leave the building. The facility does not have locked exit doors and this is how (R1) was able to leave the building, through the southwest exit door.V20, Director of Care Services for the local hospital stated in interview on 11/18/25 at 9:30 AM The facility served (R1) papers for an involuntary discharge and he has no one to advocate for him. We did a new psychological evaluation and the results were (R1) is alert and oriented, decision making skills are there also but (R1) would not be able to live alone. (R1) would not be able to take care of himself, we are asking his brother to help assist us with placement elsewhere. No progress for this goal so far. (R1) is his own person but he can not take care of himself. The Ombudsman organization is helping with the discharge process they are going to file for a hearing due to the involuntary discharge and the facility (R1) was at is the only place (R1) has been in the last 20 some years.V19, Nurse Practitioner for the contracted company who works with the mental health clients for the facility stated in interview on 11/18/25 at 12:02 PM, I agree with the assessment (R1) received at the hospital.

Based on interview and record review the facility failed to document a resident to resident altercation in the electronic medical record for two of four residents (R2, R3) reviewed for abuse in the sample list of seven. Findings include:The facility's State of Illinois Illinois Department of Public Health Long-Term Care Facility & IID -Serious Injury Incident Report dated 10/23/25 at 4:10 PM documents on 10/16/25 at 2:20 PM R2 open handed smacked R3 on R3's right upper arm. R2 stated R2 acted in retaliation claiming that R3 hit R2 first, however witnesses did not support that R3 hit R2. R2's and R3's electronic medical records (EMRs) did not include documentation of the 10/16/25 altercation. On 11/17/25 at 1:10 PM R2 stated R3 gets in people's rooms and sleeps in their beds and the facility hasn't done much about it. R2 stated there was one time that R3 got physical with R2 on an unidentified date. R3 tried to go into R2's room, R3 banged on my (R2's) arm, so I (R2) banged her (R3) back in the arm. On 11/17/25 at 1:27 PM V8 CNA confirmed V8 witnessed R2's/R3's altercation on 10/16/25. V8 stated the incident happened between 2:00 PM and 2:30 PM. V8 witnessed R3 wheel past and grab onto R2's wheelchair armrest. R2 got upset with R3, yelled at R3 and slapped R3 in the right hand three times reprimanding R3 like you would a child. R2's hit was intentional. V8 described R2 as being with it, knows staff, and alert/oriented to person, place, time and situation. V8 stated R3 is confused and in her (R3's) own world. On 11/17/25 at 12:05 PM V5 Licensed Practical Nurse was asked where V5 documented R2's/R3's incident in their EMR. V5 stated to ask V2 Director of Nursing (DON) since V2 took over the incident, and all V5 documented was that R2 was on initial constant supervision which changed to 15-minute checks. On 11/17/25 at 2:05 PM V2 DON stated resident to resident altercations are documented in risk management and confirmed this incident was not documented in R2's or R3's EMRs. V2 stated V5 was R2's nurse that day and would have made the notifications to the family and physician, which V5 usually documents in a progress note. V2 stated V15 Registered Nurse may have notified R3's family and physician, and all of this would be documented in risk management. On 11/17/25 at 3:40 PM V1 Administrator stated resident to resident altercations are documented in risk management and V1 thought staff documented the incident in the EMR in a progress note. The facility's undated Abuse Prevention Policy documents all incidents will be documented, whether or not abuse occurred, was alleged or suspected.

Based on interview and record review the facility failed to safely provide a resident wheelchair assistance, while obtaining a resident's weight, in a manner to prevent a fall. This failure resulted in a vertebra fracture for one of three residents (R1) reviewed for falls on the sample list of three. This past noncompliance occurred from 8/12/25 through 8/12/25.Findings include:R1's Diagnoses Sheet includes the following: History of Falling, Nondisplaced Fracture of Base Neck of Right Femur, Subsequent Encounter for Closed Fracture With Routine Healing, Presence Of Right Artificial Hip Joint, Aftercare Following Joint Replacement Surgery, Unspecified Osteoarthritis, Spinal Stenosis, Cervical Region, Other Intervertebral Disc Degeneration, Lumbar Region. Pain in Right Hip, Unsteadiness on Feet, Muscle Wasting and Atrophy, Not elsewhere Classified. Multiple Sites, and Unspecified Fall, Subsequent Encounter.R1's Fall Risk assessment dated [DATE] documents R1 was at high risk ( score of over 12) for falls with a score of 21.R1's Minimum Data Set (MDS) dated [DATE] documents R1's Brief Interview of Mental Status score as 10 out of a possible 15, indicating moderate cognitive impairment at the time of this assessment. The same MDS documents R1 used a manual wheelchair for mobility and required substantial to maximum assistance with transfers.R1's Health Status Note dated 8/12/2025 at 09:44 am documents the following: Note Text: Resident fell out of w/c (wheelchair) on way to get weighed this AM (morning). (The) Fall was witnessed and he did hit his head. Resident on blood thinners. C/O (complained of) pain on R (right) side where he landed. VS (vital signs) were stable at 138/64 blood pressure), P (pulse) 90, T 98.4 (temperature), R 20 (respirations), O2 (oxygen blood saturation) 91% (percent). POA (unidentified, Power of Attorney) notified at 09:35 (am). NP (unidentified Nurse Practitioner) notified at 0940 (am). Resident on (the) way to (specified hospital) ER (emergency room). On stretcher by ambulance.The facility Illinois Department of Public Health, Long-Term Care Facility and IID- Serious Injury Incident Report dated 8/13/25 document on 8/12/25, R1 had a Fall with physical harm or injury. The same report further identifies that R1 sustained a witnessed fall from the wheelchair that resulted in an acute, first lumbar - vertebral fracture.A follow-up facility Illinois Department of Public Health, Long-Term Care Facility and IID- Serious Injury Incident Report dated 8/19/25 included the summary/conclusion of R1's 8/12/25 fall, as follows: Investigation revealed: (V3, Certified Nursing Assistant/CNA) was assisting (R1) from the weight scale. As the CNA (V3) was guiding the wheelchair from the wheelchair platform (R1) fell forward from the wheelchair to the floor. The resident (R1) was unable to give a description of the incident. (V3, CNA) reported in her interview that she had backed (R1's) wheelchair onto the platform to obtain his weight. When she (V3, CNA) was pushing the wheelchair off the platform, (R1) was facing forward and fell forward out of the chair. In conclusion it was determined that the fall was the result of (R1) exiting the scale platform, facing forward and leaned forward from the wheelchair causing him to fall. (name brand-nonskid material) placed into (R1's) seat of the wheelchair. Staff were educated on safety while using the weight scale. (R1) will continue to work with therapy after his return to the facility.R1's admission Fall Care Plan dated 8/6/25 documents the following: FALLSThe resident is high risk for falls related to Gait/Balance problems. History of fall at home. Date Initiated: 08/06/2025. The resident will not sustain serious injury through the review date. Date Initiated: 08/06/2025. Anticipate and meet The resident's needs. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Drop seat wheelchair. Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. Follow facility fall protocol. Pt evaluate and treat as ordered or PRN ( as needed).R1's same care plan was updated 8/12/25 as follows: ACTUAL FALLResident sustained an actual fall 8/12/25. Resident will resume normal activity through next review date. Target Date: 11/14/2025 8/12/25 ( Name brand non-skid material) in wheelchair. 8/12/25 sent to ER (Hospital, Emergency room).R1's Hospital Records dated 8/12/25 document the following: Chief ComplaintPatient (Pt) presents with Fall: Pt here for fall from wheelchair this morning at NH (nursing home, facility). Pt there ( at the facility) for rehab following a R (right) hip replacement ( due to a fall at home) performed here. Pt complains of pain all over but emphasizes his R hip. Poor historian as Alert x2 (alert to person and place, but not time) at baseline. Unsure if he (had) LOC (loss of consciousness).HPI (History of Present Illness): (R1) is a (specified age) male with medical history of Morbid Obesity, HFpEF (Heart Failure with Preserved Ejection Fracture), HLD ( Hyperlipidemia), OSA (Obstructive Sleep Apnea) , COPD (Chronic Obstructive Pulmonary Disease), T2 d ( Type II Diabetes Mellitus) , NASH ( Nonalcoholic) Cirrhosis, Peripheral Vascular Disease, History of Right Femoral Neck Fracture Status Post Right Hip Arthroplasty on 07/29/2025 (from fall at private home), and Gastric Angiodysplasia who presents to our facility with concerns of right hip pain and low back pain secondary to mechanical fall suffered falling off wheelchair today (8/12/25 at the facility), prior to arrival. Patient had ortho (orthopedic) surgery of the right hip on 07/29. Patient was discharged (from the hospital) on August 4th (8/4/25) to rehab (Rehabilitation, at the facility) , and today patient was being weighed on a scale and fell off the wheelchair, now reporting right hip pain. Denied having had any new numbness or weakness or tingling, has had some lower abdominal pain as well as right hip pain/lower back pain. Denies headache or neck pain. History was somewhat limited in the ER (Emergency Room), but per reports the patient denies any fevers, unclear if having worsening pain of the right hip over the last few days. Otherwise stating that patient is doing well, no other complaints at this time. R1's same Hospital Record dated 8/12/25 documents diagnoses addressed at the hospital included: Ground-level fall Closed fracture of first lumbar vertebra, unspecified fracture morphology, initial encounter. (non-surgical interventions)On 10/09/25 at 11:00 am R1 was lying in a low bed, on his back, with oxygen actively being administered. Multiple fall interventions were identified. R1's call light was in reach. One - quarter bedside rail was securely attached. A full, bed length, fall mat laid beside R1's bed. R1's wheelchair was close to the foot of R1's bed, in the locked position. R1's wheelchair cushion had nonskid fabric above and below. There was a wall sign present to remind resident to use his call light for assistance with transfers. R1 confirmed the interventions identified were in place because R1 had several falls in the facility. R1 stated an additional intervention for his falls included staff come into his room more frequently to ask him if he needs to go to the bathroom. R1 also stated the first fall he had was at his home. He fell and fractured right hip. R1 said his (unidentified family members) would have to give the details of that fall at home, as resident does not recall the event, until he woke up in the hospital post right hip surgery. R1 said that the first fall at home with the fracture, is the reason he had to be admitted to the facility 8/4/25, for therapy.R1 also stated he has had other falls in the facility, that were his own fault though, he can't recall the dates. R1 stated Twice I was getting up on my own. I should have asked for help. One fall I was horsing around in activities with another resident and the activity director. We were playing deal or no deal. At one point the activity staff had his head under a blanket reaching for prizes. I was just being silly. I was going to pour a little water on his head as he bent over. The other resident and I were cutting up. As I stood up with the glass of water, we were laughing. I tripped over my own feet, or maybe mine and his feet. I had a skin tear on my thumb is all. My pride was hurt. That was my own fault. I have also self-transferred in my room on those two separate occasions. They have a sign up (points to the wall sign) to remind me to use the call button for help. They also started the frequent bathroom offers. R1 also stated I had one fall that was the CNA's (later identified as V3, Certified Nursing Assistant) fault. She pulled my wheelchair backwards up the ramp of the scale. After she weighed me, the CNA let go of the wheelchair. I went down the ramp fast and went headfirst, and fell out of the wheelchair. I don't have any problem with my balance when seated. Usually, the CNA's will push me forward up the scale ramp, and back me down the slope after. They usually hold onto the wheelchair the whole time. Not that time. R1 then points across his room to the hallway. R1 said Look at ramp on the scale and you will see what I mean. It is right across the hall.On 10/09/25 at 11:15 am V5, Licensed Practical Nurse (LPN) entered a clean utility room where the platform wheelchair scale sat. There was platform approximately four foot wide, by four-foot-long wheelchair scale. The scale had a declining ramp off the platform that tapered approximately three to four inches down to the floor. V5, LPN confirmed the scale decline. V5, LPN stated residents are not safe to propel themselves forward down the sloped ramp. All CNA's know they are to push the resident up the ramp facing forward and pull the residents back down the ramp backwards, so they (residents) don't fall forward. Nursing staff all got educated that same day ( 8/12/25). Some by phone and some in person. We each had to return demonstration, to confirm understanding for safe weighing procedure. V5, LPN also stated (R1) has had a couple other falls self-transferring without injury. Het did sustain a lumbar fracture from the fall 8/12/25. He did not require surgical repair.On 10/9/ 25 at 11:55 am V2, Director of Nursing (DON) observed the facility, resident commercial, wheelchair weight scale in the clean utility room. V2, DON confirmed there was an approximately four-foot wide by four-foot-long weight platform, that sat at the top of a three-to-four-inch, sloped wheelchair ramp. V2, DON explained that the facility re- enacted the process V3, Certified Nursing Assistant (CNA) used to obtain R1's weight on 8/12/25. V2 stated she identified right away that V3, CNA had guided R1 up the ramp backward while R1 was facing forward. R1's wheelchair then rolled down the ramp with R1 facing forward. R1 fell forward out of the wheelchair. V2, DON then stated We (the facility) takes full responsibility for (R1's) fall 8/12/25, because (V3, CNA) pulled (R1) up (the wheelchair scale ramp) backwards resulting in (R1) facing forward on the way back down the slope. (R1) should have been pushed up the slope, weighed, and then exited the scale with the (V3, CNA) guiding his wheelchair backwards down the slope.o The facility policy Fall Guideline documents the following: Purpose: To consistently identify and evaluate residents at risk for falls and those who have fallen to treat or refer for treatment appropriately and develop an organization-wide ownership for fall prevention to:To achieve each resident's maximum potential of physical functioning.To prevent or reduce injuries related to falls.To enhance residents' dignity and self-worth. To rehabilitate residents to their fullest potential of function.The same policy documents:The intent of this guideline is the ensure this facility provides an environment that is free from hazards over which the facility has control and provides appropriate supervision to each resident as identified through the following process: Identification of hazards and risksEvaluation ImplementationMonitoringAnalysisPrior to the survey date of 10/9/25, the facility had taken the following action to correct the noncompliance:1. On August 12, 2025, the facility Compliance Assurance Committee developed a plan of correction for the 8/12/25 fall incident.2. On August 12,2025, the facility reviewed the procedure for weighing residents to ensure accuracy.3. On August 12, 2025, all facility staff were in-serviced on the safe and proper procedure for obtaining resident weights.4. Subsequent weights since 8/12/25 were observed and determined by the Quality Assurance process to have been safely completed per policy.

Based on interview and record review the facility failed to provide the services of a registered nurse for eight consecutive hours seven days a week every twenty-four hours. This failure has the potential to affect all 65 residents who reside in the facility.The Long-Term Care Facility Application for Medicare and Medicaid dated 9/7/25 documents 65 residents reside at the facility.The facility's Staffing Policy that is not dated was provided by V1 Administrator and documents that a Registered Nurse (RN) will be scheduled seven days a week at least one continuous (8) eight-hour shift. The facility's nursing work schedule for the month of August 2025 and September 2025 documents the facility did not have the services of a RN for eight consecutive hours on 8/25/25, 8/30/25, and 9/10/25. The facility's 24-Hour staffing sheet dated Wednesday, September 10, 2025, documents that there were no RN's scheduled during this 24-hour period. The facility assessment dated [DATE] documents that facility accepts residents with a variety of clinically complex conditions. The facility assessment documents that Registered Nurses are provided by the facility.On 9/09/25 at 8:29 AM, V1 Administrator confirmed there were no Registered Nurses on duty for eight consecutive hours on 1/1/25, 3/31/25, 8/25/25, and 8/30/25. On 9/09/25 at 1:15 PM, V1 Administrator confirmed there were no Registered Nurses on duty for eight consecutive hours on 9/10/25.

Based on interview and record review the facility failed to develop and implement interventions and monitoring for hyponatremia (low sodium) with repeated hospitalizations for one of three residents (R40) reviewed for hospitalizations in the sample list of 33.R40's Minimum Data Set (MDS) dated [DATE] documents R40 has moderate cognitive impairment.R40's September 2025 Medication Administration Record (MAR) documents R40 receives the following psychotropic medications: Fluoxetine 60 milligrams (mg) by mouth (PO) daily, Mirtazapine 15 mg PO daily, Olanzapine 22.5 mg PO daily, Divalproex 500 mg PO twice daily, and Clorazepate Dipotassium 7.5 mg PO daily.R40's emergency room Discharge Instructions dated 5/2/25 documents the following: R40 had hyponatremia and urinary tract infection, follow up with V21 Physician within 2-4 days, and R40 will need sodium level rechecked as it was low today, 128 (normal range 135-145). Some seizure medications and antidepressants can affect sodium levels. Treatment for hyponatremia depends on the cause and may include intravenous (IV) fluids, medication to correct the sodium imbalance, adjustments in medications causing the hyponatremia, and limiting water or fluid intake. R40's Hospital History and Physical dated 5/15/25 documents R40 was transferred to the hospital following a fall. R40's Sodium was 124, R40 was admitted with acute on chronic hyponatremia, urinary tract infection, and pneumonia, and R40 was given 1 liter of Normal Saline IV. R40's Hospital Note dated 5/20/25 documents laboratory workup confirmed Syndrome of Inappropriate Antidiuretic Hormone Secretion (a condition that leads to excessive water retention and low sodium levels) improved with fluid restriction which was lifted on 5/19/25 when R40's sodium was 135.R40's physician orders dated 5/21/25 and 5/22/25 document to obtain Comprehensive Metabolic Panel (CMP). R40's Progress Note dated 6/2/25, recorded by V19 Nurse Practitioner, documents to recheck CMP. There is no documentation in R40's electronic medical record that a CMP was completed as ordered on these dates, and there is only one CMP that was completed on 7/14/25.R40's Hospital History and Physical dated 7/2/25 documents R40 was sent to the hospital for altered mental status, R40's sodium level was 120, serum osmolality was 265 (normal range 280-300), and urine sodium was less than 15. It was suspected that R40 was experiencing hypovolemic hyponatremia, but R40 reported having good oral intake and denied vomiting/diarrhea. R40 admitted with hyponatremia, and was given intravenous fluids.R40's Hospital Note dated 8/15/25 documents R40 was transferred to the hospital due to urinary retention, altered mental status, lethargy; and the facility reported R40 was given IV fluids and catheter was changed, but no output. R40's sodium level was 125 and R40's admission diagnoses included acute encephalopathy likely secondary to urinary tract infection and hyponatremia. R40's Hospital Note dated 8/16/25 documents R40's sodium level had increased to 134.R40's active care plan does not address a problem, goals, and interventions to address R40's reoccurring hyponatremia. R40's active physician's orders as of 9/8/25, do not document any routine laboratory orders (labs).On 9/07/2025 at 8:31 AM R40 was unable to provide details regarding his hospitalizations within the last six months.On 9/09/2025 at 10:15 AM V7 Licensed Practical Nurse stated you would have to talk to the DON (V2 Director of Nursing) about that, when V7 was asked what was being done to address R40's hyponatremia. V7 stated labs are done upon readmission and routinely as ordered by the provider.On 9/9/25 at 10:31 V2 DON was asked about interventions regarding R40's hyponatremia. V2 stated R40 receives intravenous vitamin infusions monthly. V2 confirmed R40's care plan should address hyponatremia and interventions. At 12:47 PM V2 confirmed R40's care plan does not address hyponatremia and V23 MDS/Care Plan Coordinator did not care plan for this problem due to thinking it was an acute condition. At 2:35 PM V2 confirmed R40's monthly vitamin infusion was the only intervention for R40's hyponatremia. V2 confirmed R40 does not have any orders for routine monitoring of sodium level. V2 confirmed R40's orders for sodium level after hospital discharge on [DATE] and on 5/21/25, and confirmed there is no documentation these orders were completed. V2 stated the facility uses the laboratory at the local hospital. At this time V2 called the local hospital laboratory and confirmed R40 did not have any labs drawn between 5/2/25 and 7/1/25, other than the labs drawn in the emergency room.On 9/9/25 at 3:22 PM V19 Nurse Practitioner stated the cause of R40's hyponatremia is likely due to his psychotropic medications, R40 takes Zyprexa which affects sodium. V19 stated due to R40's psychiatric diagnoses R40's psychiatric medications shouldn't be adjusted. V19 stated V19 does not feel comfortable ordering a routine dose of sodium bicarbonate due to R40's sodium level fluctuating. V19 stated V2 just spoke with V19 regarding the concerns with monitoring and interventions for R40's hyponatremia, V19 gave orders for monthly Basic Metabolic Panel and adjustments can be made to R40's monthly IV vitamin infusions. V19 confirmed R40's hyponatremia could have been identified prior to R40's hospitalizations if labs were completed as ordered and R40's decline could have been identified sooner. V19 stated hyponatremia was not the primary admitting diagnosis for his hospitalizations. V19 stated if R40's hyponatremia was identified sooner and reported to V19, V19 would have ordered a short-term sodium supplement and to recheck R40's labs. V19 stated if hyponatremia is undetected/untreated it can lead to neurological side effects such as dizziness, lethargy, confusion, and altered mental status; and if severe it can cause seizures. The facility's undated Physician Order Guideline documents nurses are responsible for executing the physician's orders, place orders into the resident's electronic medical record, and contact laboratory services as required to execute the order.

Based on observation, interview, and record review the facility failed to implement Enhanced Barrier Precautions (EBP), perform hand hygiene, properly disinfect equipment and maintain a urinary catheter bag off the floor for three of 17 residents (R12, R40, R43) reviewed for infection control in the sample list of 33. 1.) On 9/07/2025 at 8:31 AM R40's door contained a sign indicating R40 was on EBP and to wear gown and gloves for high contact care, including assistance with dressing, transfers, and care of indwelling devices. PPE (Personal Protective Equipment) was present in a container on R40's door. R40 was lying in bed and R40's urinary catheter drainage bag was on the side of the bed. R40 stated R40 has had the catheter for a few months and has had urinary tract infections (UTIs). R40 stated the staff do not wear gown and gloves when providing R40's cares. On 9/07/2025 at 9:03 AM V18 Certified Nursing Assistant (CNA) entered R40's room, transferred R40 out of bed and into the wheelchair, and changed R40's bed linens. V18 was not wearing gloves or a gown for this care. On 9/08/2025 at 11:34 AM V14 CNA entered R40's room, transferred R40 out of bed, and assisted R40 to walk down the hallway using a wheeled walker and gait belt. V14 was not wearing any PPE for R40's cares. At 11:45 AM V14 stated R40 is on EBP for his urinary catheter and staff wear gown only when doing catheter related care. V14 confirmed V14 does not wear a gown and gloves when assisting R40 with dressing and transfers. On 9/08/2025 at 1:35 PM V11 CNA entered R40's room, emptied R40's catheter, and V11 was not wearing a gown. On 9/8/25 at 1:39 PM V18 CNA assisted R40 to standing position and back into bed and placed the catheter drainage bag on the bottom of the bed frame causing the bottom half of the bag to be on the floor. V18 provided R40's urinary catheter care/cleansing. V18 wore gloves but did not wear a gown during R40's care and did not perform hand hygiene prior to or after R40's catheter care. V7 Licensed Practical Nurse applied a catheter securement device to R40's left thigh and attached the urinary catheter. V7 did not wear a gown for R40's catheter care. On 9/08/2025 at 2:02 PM V18 was asked about EBP. V18 stated V18 thought it had to do with using a towel as a barrier on the overbed table during catheter care or applying barrier cream. V18 confirmed he does not wear a gown for any of the cares listed on the EBP sign on R40's door. V18 stated he was not aware of EBP. V18 confirmed V18 did not perform hand hygiene prior to or after providing R40's catheter care. On 9/9/25 at 11:40 AM V18 confirmed R40's catheter drainage bag was touching the floor during R40's observed catheter care and confirmed catheter bags are supposed to be kept off of the floor. On 9/08/2025 at 2:09 PM V7 stated EBP is followed when dealing with R40's urine and catheter. V7 was not aware that a gown should be worn for any other cares, only if it deals with the catheter. R40's May-September 2025 Nursing Notes document R40 received antibiotic treatment for UTIs on at least four different occasions. R40's Nursing Note dated 8/19/2025 documents R40 admitted to the hospital for UTI with methicillin resistant staphylococcus aureus, an MDRO. 2. On 09/08/2025 4:33 PM a sign was present on R43's door indicating R43 is on Enhanced Barrier Precautions. At this time V27 Registered Nurse accessed R43's feeding tube and V27 did not wear a gown. 3. On 09/09/2025 at 10:45AM V13 Licensed Practical Nurse completed wound care for R12. V13 donned a gown and gloves after completing hand hygiene with alcohol-based hand cleanser. V13 removed the old dressing from R12's wound which was dated 9/8/25 and removed iodoform gauze. V13 cleaned the wound with wound cleanser, cotton tipped applicators, and gauze pads. V13 discarded V13's gloves and cleansed hands then donned clean gloves. V13 inserted clean iodoform gauze strips into R12's tunneling stage IV Pressure Ulcer. The wound was draining large amounts of gray, brown liquid and was odorous. V13 cut the Iodoform packing with the scissors she had in the room. V13 then covered the wound with a super absorbent gauze pad and bordered foam dressing. V13 took the scissors to the utility room and cleaned the scissors with soap and water after using them to cut gauze strips in R12's draining wound. No bleach solution was used. V13 stated I guess I should have used a bleach wipe to clean the scissors. The facility's EBP policy dated 3/21/25 documents EBP is implemented to prevent the transmission of multidrug-resistant organisms (MDRO), gown and gloves are worn during high-contact resident care activities for residents colonized or infected with MDRO and for those at increased risk of acquiring MDRO through wounds or indwelling medical devices. This policy documents staff should be trained on EBP upon hire and annually, signage will be posted outside of the resident's room to identify precautions, Personal Protective Equipment (PPE), and high contact care activities that requires the use of gown and gloves. This policy documents high-contact resident care activities includes assistance with dressing, bathing, transferring, hygiene, changing linens, toileting/incontinence, device care, and wound care. The facility's Urinary Catheter Care policy dated September 2005 documents to be sure the catheter tubing and drainage bag are kept off the floor and to perform hand hygiene prior to and after performing urinary catheter care. The facility's Handwashing/Hand Hygiene Policy dated March 2020 documents staff should practice hand hygiene/handwashing as primary means in preventing the spread of infection and alcohol-based hand rubs can be used as hand hygiene when hands are not visibly soiled or contaminated. This policy documents hand hygiene should be performed after handling potentially contaminated equipment or medical devices.

Based on interview and record review the facility failed to ensure physician visits are documented for one of three (R40) residents reviewed for hospitalization in the sample list of 33. The facility's undated Physician Services Policy documents It is the policy of this facility that each resident admitted to this facility is under the care of a physician licensed in the State and that all physician services will comply with State and Federal regulations for resident care in a licensed facility. The attending physician shall write a progress note at the time of each resident visit and review the resident's total program of care; i.e. (in other words) comprehensive assessments, care plans, medication and treatments, and approving such by signing and dating the current order recap.R40's active census documents R40 has resided in the facility since 2004 and V21 Physician/Medical Director is R40's primary physician. This census documents R40 was hospitalized six times within the last year. R40's electronic medical record does not contain any physician visit notes by V21 within the last year, only specialists and nurse practitioner notes. On 9/10/2025 at 9:28 AM V1 Administrator stated V1 was unable to locate R40's physician progress notes by V21. V1 stated V1 was unsure when R40 was last seen by V21.On 9/10/2025 at 11:20 AM V21 stated V21 keeps his progress notes and does not document his visit notes in the residents' electronic medical record. V21 stated the facility would have to request his notes. V21 stated yesterday the facility requested R40's physician visit notes, but V21 was unable to locate any. V21 stated V21 has evaluated R40, but was unable to give a specific date or provide the last physician progress note. V21 stated V21 searched R40's name and did not find any notes in the database.

Based on interview and record review the facility failed log infections, organisms, and antibiotics and ensure the appropriate antibiotics were administered for one (R40) of five residents reviewed for infection control on a sample list of 33. Findings include:The facility's Antibiotic Stewardship Program Guidelines dated 4/29/2024 document that the purpose of the antimicrobial stewardship program is to improve antimicrobial stewardship practices and to monitor outcomes and antimicrobial use. This policy documents that the objective is that the Antimicrobial Stewardship Program will be to improve patient outcomes through optimization of antimicrobial therapy by selection of appropriate antibiotic dose, route, and duration of treatment, minimize the development of antimicrobial resistance by appropriately selecting antibiotics, and reduce the rates of facility-acquired infection. Guidelines document that the facility will monitor antibiotic use and outcomes from antibiotic use. The facility's Infection and Prevention and Control Program dated 1/24/24 documents that the facility's Infection Prevention and Control Program (IPCP), is based upon information from the Facility Assessment including the Infection Control Risk Assessment and follows national standards and guidelines to prevent, recognize and control the onset and spread of infection whenever possible. R40's urine culture results dated 5/2/25 document that there was mixed flora (multiple species present) in R40's urine and no sensitivity was performed. On 9/10/25 at 8:56 AM, V4 Infection Preventionist (IP) stated that on May 2, 2025, R40 did have his urine checked for infection and it was a contaminated. V4 stated R40 was put on an antibiotic (Cephalexin 500 milligrams) and that there was no need to repeat the urine test. emergency room (ER) records for R40 document that R40 was seen in the ER on [DATE] and a Computed Tomography scan determined that R40 had inflammation of R40's urinary bladder and pneumonia. These ER notes document that R40 initially received antibiotics Vancomycin and Zosyn and then Ceftriaxone was added based on urine culture results that determined R40 had a urinary tract infection (UTI). The facility's Infection Surveillance Monthly Report dated May 2025 does not document any UTI's or antibiotic usage for R40. 9/9/25 at 3:22 PM, V19 Nurse Practitioner stated she did not see another urine culture following R40's 5/2/25 result that indicated mixed flora. V19 stated mixed flora would be considered as contaminated and therefor it is unknown if he had a true infection. V19 stated you don't know if the antibiotic was the appropriate drug of choice without culture and sensitivity results. V19 confirmed that part of antibiotic stewardship is ensuring the bacteria are susceptible to the antibiotics ordered. V19 confirmed the hospital discharged R40 on Keflex for UTI and this culture was completed at the hospital. V19 stated the hospital is not very good about following up on culture results after a resident discharges from the hospital. V19 stated she wouldn't have ordered a re-culture unless he was symptomatic. V19 reviewed R40's progress notes and stated the staff were documenting that R40 was asymptomatic after returning from the hospital.The facility's Infection Surveillance Monthly Report dated July 2025 documents that R40 began receiving an antibiotic (Ertapenem Sodium) on 7/7/25 for an unknown infection. On 9/10/25 at 8:56 AM, V4 IP could not confirm what organism R40 was being treated for on 7/7/25 and that it should have been documented on the Infection Surveillance log.Progress notes from R40's electronic medical record dated 8/19/25 document that a nurse from the hospital called the facility to report that R40 was returning to the facility with a diagnosis of UTI with staph/MRSA.The facility's Infection Surveillance Monthly Report dated 8/19/25 documents that R40 was receiving an antibiotic (Bactrim) for a UTI but does not include that R40 was being treated for Methicillin-Resistant Staphylococcus Aureus (MRSA).On 9/10/25 at 8:56 AM, V4 IP stated that R40 did have a diagnosis of UTI with MRSA and that it should have been listed on the Infection Surveillance log. V4 provided R40's Case Detail dated 8/19/25 documenting R40's MRSA of R40's urinary tract.

Based on interview and record review the facility failed to ensure timely physician visits for one of three residents (R40) reviewed for hospitalizations in the sample list of 33. The facility's undated Physician Services Policy documents It is the policy of this facility that each resident admitted to this facility is under the care of a physician licensed in the State and that all physician services will comply with State and Federal regulations for resident care in a licensed facility. The attending physician shall write a progress note at the time of each resident visit and review the resident's total program of care; i.e. (in other words) comprehensive assessments, care plans, medication and treatments, and approving such by signing and dating the current order recap. The attending physician shall certify upon admission and at each visit every 30/60 days thereafter what level of care the resident requires, and document the (reason) for a change in the progress notes.R40's active census documents R40 has resided in the facility since 2004 and V21 Physician/Medical Director is R40's primary physician. This census documents R40 was hospitalized six times within the last year. R40's electronic medical record does not contain any physician visit notes by V21 within the last year, only specialists and nurse practitioner notes. On 9/10/2025 at 9:28 AM V1 Administrator stated V1 was unable to locate any of R40's physician progress notes by V21. V1 stated V1 was unsure when R40 was last seen by V21.On 9/10/2025 at 11:20 AM V21 stated V21 rounds at the facility monthly, but does not see each resident every month. V21 was asked how often V21 evaluates each resident. V21 stated the facility has a fully licensed Nurse Practitioner (V19) that is in the facility frequently to see residents. V21 stated yesterday the facility requested R40's physician visit notes, but V21 was unable to locate any. V21 stated V21 believes he evaluated R40, but was unable to give a specific date or provide R40's last physician progress note.

Based on observation, interview, and record review the facility failed to have physician's orders for the use and care of Continuous Positive Airway Pressure (CPAP) for one of one resident (R25) reviewed for CPAP use in the sample list of 33. The facility's CPAP/BiPAP (Bilevel Positive Airway Pressure) Support policy dated April 2007 documents to review the physician's order to determine the oxygen flow rate and positive end-expiratory pressure settings. This policy includes to document a general assessment prior to the procedure, time/duration of therapy, CPAP settings, oxygen flow rate, oxygen saturation, and how the resident tolerated the procedure. On 9/07/2025 at 9:27 AM There was a CPAP machine on the overbed table next to R25's bed. The CPAP mask and tubing was in a plastic bag attached to the machine. R25 stated R25 has been in the facility for a few weeks and uses the CPAP at night. R25 stated the staff do not do any care for the CPAP. R25's active census documents R25 admitted to the facility on [DATE]. As of 9/7/25 R25's active physician's orders do no document any orders for the CPAP. There is no documentation in R25's medical record of CPAP use and care/cleaning. On 9/7/25 at 2:15 PM V7 Licensed Practical Nurse (LPN) stated V7 wasn't aware that R25 was using a CPAP. V7 stated there should be a physician's order for settings and night shift provides CPAP care for the tubing and mask cleaning/changes. On 9/07/2025 at 2:20 PM V22 LPN stated R25 was on V22's hall when R25 first admitted and R25 was not using a CPAP at that time. V22 was unsure when R25 started using the CPAP. V22 stated night shift documents CPAP care on the Treatment Administration Record. On 9/07/2025 at 2:24 PM V7 Certified Nursing Assistant stated R25 has been using the CPAP for a few nights. On 9/07/2025 at 2:33 PM V2 Director of Nursing stated CPAP masks should be cleaned weekly with soap and water and there should be a physician order for the CPAP settings. V2 stated V2 was not aware that R25 had a CPAP, and V2 will follow up and obtain orders.

Based on observation, interview and record review the facility failed to assess/measure a pressure sore, administer a wound treatment according to physician's orders and accurately document the location of a pressure sore for one resident (R12) of two residents reviewed for pressure sores in a sample list of 33. Findings Include: R12's Care Plan updated 6/16/25 lists the following diagnoses: Hypomagnesemia, Chronic Pulmonary Edema, Quadriplegia, C5-C7 Complete, Neuromuscular Dysfunction of Bladder, Seizures, Cauda Equina Syndrome, Zoster Encephalitis, and Primary insomnia. R12's MDS Minimum Data Set, dated [DATE] documents R12 is cognitively intact. R12's admission Skin assessment dated [DATE] documents a Superficial wound (to the) Right Gluteal Fold measuring 0.2cm (centimeters) in Length by 0.2cm in width by 0cm in depth. R12's Physician's Order sheet documents a physician's order started on 4/24/25 and discontinued on 5/15/25 R (right) upper thigh. Cleanse with normal saline. Apply Mepilex every day shift every 3 day (s) for wound. R12's 4/28/25 Skin assessment tool is completely blank. R12's 5/7/25 Skin assessment tool does not contain measurements but documents Continue Mepilex treatment to Right Gluteal fold. Wound prevention had superficial wound. R12's 5/12/25 Skin assessment tool is completely blank.On 6/10/25 at 11:30AM V1 administrator and V26, Corporate Registered Nurse verified no wound assessments were completed on 4/28/25,or 5/12/25 and no wound measurements were completed 5/7/25. V26 stated I see the wound assessments were left blank on 4/28/25 or 5/12/25 and no measurements were documented 5/7/25. If the wound assessments were done they would have been documented on the blank wound assessments.R12's Physician's Order sheet documents a physician's order started on 5/17/25 and discontinued on 5/22/25 Right gluteal fold Cleanse with wound cleanser. Apply collagen to wound bed then cover with hydrocolloid dressing 3x (times) a week et PRN (and as needed) every day shift every Tue, Thu, Sat (Tuesday, Thursday, Saturday) for wound. On 9/10/25 at 1045AM V22, Licensed Practical Nurse (LPN) stated (R12) had just one wound. Some people charted it as the right upper thigh and others charted it as the right gluteal fold. It was the same wound. V22 verified that she has been with the facility several years and regularly cares for R12 and does his treatment. R12's Wound Assessment and Plan by V25, Wound Care Nurse Practitioner dated 5/15/25 documents R12 had a Stage III Pressure Ulcer 0.5cm long by 1.5cm in width by 0.5cm in depth. Wound onset date 4/21/25, Site: Right Gluteal Fold. R12's Wound Assessment and Plan by V25, Wound Care Nurse Practitioner dated 5/22/25 documents the wound had increased in size to 1.0cm long by 1.9cm in width by 0.5cm in depth. There is no documented assessment 5/29/25. R12's Wound Assessment and Plan by V25, Wound Care Nurse Practitioner dated 6/5/25 documents the wound had increased in size to 1.5cm long by 1.0cm in width by 1.6cm in depth and now has a moderate amount of exudate. R12's Wound Assessment and Plan by V25, Wound Care Nurse Practitioner dated 6/12/25 documents the wound had increased in size to 1.5cm long by 1.5cm in width by 2.6cm in depth. R12's Wound assessment and Plan by V25, Wound Care Nurse Practitioner dated 6/20/25 documents the wound had increased in size to 1.0cm long by 1.7cm in width by 2.1cm in depth. The wound is now documented to be a stage 4 pressure sore and there is 0.6cm of tunneling at 12:00 o'clock.On 9/9/25 at 4:29PM V25 stated There was only one wound which was present on admission. My expectation would be that as soon as any wound even a superficial wound is identified a treatment even if it is just barrier cream and regular accurate assessment of the wound should be put in place. I would like to be notified by the facility of any wound as soon as possible.The facility's Quality Assurance Meeting notes dated 6/19/25 document (V25) Wound NP (Nurse Practitioner) and (V4, Licensed Practical Nurse) RCC (Resident Care Coordinator) were doing wound rounds and noted (R12) treatment in place was not the correct treatment per order. On 6/10/25 at 11:30AM V1 administrator and V26, Corporate Registered Nurse verified they were aware of the wrong treatment being in place to R12 on 6/19/25. On 09/09/2025 at 10:45AM V13 Licensed Practical Nurse completed R12's wound care. At that time R12's wound was draining large amounts of gray brown liquid and the wound was odorous.

Based on interview and record review the facility failed to provide written notice of transfer and bed hold for hospitalizations for one of three residents (R13) reviewed for hospitalizations in the sample list of 33. The facility's Bed Hold and readmission Policy dated November 2016 documents it is the facility's policy to readmit residents after hospitalization and the facility will hold a specific bed or make available the next semi-private accommodation if the resident chooses not to hold the specific bed. This policy documents the resident/representative shall be informed of this policy on admission and at the time of transfer to a hospital, and provided written notification at the time of transfer. This policy documents in the event of an emergency hospitalization the resident/representative can be notified by telephone and may verbally give the bed hold determination, which should be documented in the progress notes and follow up written confirmation may be required. On 9/07/2025 at 10:47 AM R13 stated R13 goes to the hospital 3-4 times per year. R13 could not elaborate further on what R13 was hospitalized for. R13's ongoing census documents R13 was hospitalized [DATE]-[DATE], 6/6/26, 7/18/25-7/19/25, and 7/31/25-8/5/25. R13's electronic medical record does not contain documentation that a written notice of transfer and bed hold was provided for R13's 4/15/25 and 7/18/25 hospitalizations. On 9/08/2025 at 11:49 AM V7 Licensed Practical Nurse stated bed hold/transfer notices are documented under the assessments tab of the resident's electronic medical record (EMR) and are printed and given to the resident upon discharge to the hospital. On 9/8/25 at 12:00 PM V2 Director of Nursing stated bed hold/transfer notices are provided upon discharge to the hospital and have been faxed to the hospital in the event of an emergent transfer. V2 stated bed hold/transfer notices are documented under the assessments or uploaded as a paper form into the miscellaneous section of the resident's EMR. At 1:05 PM V2 provided R13's written notice of bed hold/transfers dated 4/13/24, 6/6/25 and 7/31/25. V2 confirmed there was no documentation of written bed hold/transfer notice for R13's 4/15/25 and 7/18/25 hospitalizations.

Based on interview and record review the facility failed to provide quarterly statements of personal funds accounts for two of two residents (R4, R8) reviewed for personal funds in the sample list of 33The facility's undated Quarterly Trust Statements Policy documents quarterly statements are sent out by the last day of the following month by the business office. This policy documents to make two copies of the statements, one to keep for records and one to give to the resident/responsible party. This policy documents to keep a spreadsheet and indicate next to the resident's name when a copy was mailed to the resident's representative, and attach a copy of the statement. This policy documents to have the resident sign his/her name on the spread sheet to indicate they received their quarterly statement and upload a copy of the statement into the resident's electronic medical record. 1.) On 9/7/25 at 8:59 AM R8 stated R8 has money in a personal funds account, but R8 does not know how much money is in the account and doesn't receive quarterly statements. On 9/9/25 at 12:04 PM V20 (R8's Guardian) confirmed R8 has a personal funds account at the facility. V20 stated V20 receives billing statements from the facility, but was unsure if the facility sends quarterly statements of R8's personal funds account. R8's Statement dated 9/9/25 documents accounting of deposits, withdrawals, and interest 11/21/24-9/9/25. There is no documentation when R8's quarterly statements were sent to V20. 2.) On 9/7/25 at 9:48 AM R4 stated R4 has money in a personal funds account, but R4 does not know how much money is in the account and doesn't receive quarterly statements from the facility. R4's Minimum Data Set, dated [DATE] documents R4 as cognitively intact. R4's active profile documents R4 as responsible party/guarantor (handles her own finances.) R4's Statement dated 9/9/25 documents accounting of deposits, withdrawals, and interest 6/2/24-9/3/25. There is no documentation when R4's quarterly statements were provided. On 9/09/2025 at 11:48 AM V24 Business Office Manager stated personal funds account statements are provided to the residents quarterly and upon request. V24 stated R8's statements are sent to V20 and R4's statements are given to R4. V24 stated V24 does not have documentation when the statements are provided and doesn't have the residents sign when their statements are provided. V24 stated V24 used to document when statements were provided, but has no longer been doing that since the facility changed ownership.

Based on interview and record review the facility failed to honor a female resident's request to have her shower done by female staff for one (R14) of one resident reviewed for choices on a sample list of 33.Findings include:The facility's Resident Rights Guideline dated 10/2023 documents that it is the practice of the facility to provide for an environment in which residents may exercise their rights, each day. Residents have certain rights and protections under Federal law. This policy documents that the facility will meet and provide these rights through care and related services at all times. R14's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of fifteen indicating that R14 has normal cognitive function.On 9/07/25 at 9:12 AM, R14 stated that she doesn't want V16 male Certified Nursing Assistant (CNA) helping R14 with shower because V16 doesn't get R14 clean. R14 stated she told V11 CNA and R14 was told that R14 would have to take her shower in the evening if R14 didn't want V16 helping. R14 stated R14 was agreeable to that but that nothing has changed.R14's MDS Section GG0130 (Self-Care Shower/bathe self) dated 12/13/24 documents that R14 requires supervision or touching assistance with bathing including washing, rinsing, and drying self.R14's Care Plan dated 11/18/24 documents that R14 requires supervision assistance with Activities of Daily Living (ADL's) and partial assistance with showering. This Care Plan lists an intervention for staff to provide supportive care, and assistance with mobility as needed. A 30-day lookback at R14's electronic medical record and shower sheets documents that R14 received showers with help from V16 male CNA on 8/13/25, 8/18/25, 8/20/25 8/25/25, 9/01/25, and 9/03/25.On 9/08/25 at 9:44 AM, V6 CNA stated R14 asked V6 that morning if V6 could be the one to help R14 with her shower. On 9/09/25 at 10:04 AM, V11 CNA stated V16 CNA does help R14 with showers sometimes.On 9/08/25 at 1:53 PM, V2 Director of Nursing stated that it is R14's right to choose who helps R14 with showers. V2 stated that she was not aware R14 wanted only females helping with R14's showers and that V2 would look into it.

Based on interview and record review the facility failed to protect resident's right to be free from verbal abuse. This failure affected two of four residents (R1, R3) reviewed for resident rights on the sample list of four. Findings Include:The facility's undated Abuse policy documents Verbal Abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance, regardless of an individuals' age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to, threats of harm, saying things to frighten a resident. R1's Medical Diagnoses List dated August 2025 documents R1 is diagnosed with Schizoaffective Disorder, Bipolar Disorder, Anxiety Disorder, and Insomnia. R1's Minimum Data Set, dated [DATE] documents R1 is cognitively intact. R1's Behavior Tracking for July 2025 through August 2025 documents R1 exhibits behaviors of attention seeking, repetitive questions/statements, invading the personal space of others, pacing, inappropriate comments, false allegations, manipulation, and insomnia. R1's Care Plan dated 8/14/25 documents R1 exhibits behaviors of attention seeking, repetitive questions/statements, invading the personal space of others, pacing, inappropriate comments, false allegations, manipulation, and insomnia. Staff are to intervene as necessary to protect the rights and safety of others. R3's Medical Diagnoses List dated August 2025 documents R3 is diagnosed with Bipolar Disease, Anxiety, and a Mild Cognitive Impairment. R3's Minimum Data Set, dated [DATE] documents R3 is cognitively intact. R3's Care Plan dated 2/11/25 documents R3 exhibits behaviors caused by anxiousness with agitation which leads to verbal outbursts, mocking, yelling and demanding of others, sleep disturbances, refusal of care and false allegations. On 8/17/25 at 2:27 PM V9 Certified Nurses Assistant stated R1 has a lot of anxiety and needs constant attention and reassurance. R1 will follow staff into other resident's rooms and will not listen when you ask her not to do things. R1 will invade other resident's privacy and is hard to redirect. R1will get into staff or resident's faces when asking them repetitive questions. V9 stated R3 has verbally threatened R1. On 8/17/25 at 2:00 PM V5 Certified Nurses Assistant stated R3 yelled at R1 and stated R1 should get the f*** (expletive) out of here or she will break R1's hand. On 8/17/25 at 2:51 PM V9 Certified Nurses Assistant stated R3 is always telling R1 to shut up and go away. On 8/17/25 at 5:15 PM R3 stated R1 makes her very anxious and annoys her. R3 stated R1 follows staff around the entire shift. R3 stated there are times where she has gotten so annoyed with R1, that she has threatened her. R3 stated R1's behavior causes her great anxiety. It is hard for her to be around R1 and she is trying to be better. On 8/17/25 at 4:45 PM V1 Administrator confirmed that R3, threatening R1, could be considered verbal abuse. V1 also confirmed R1's behaviors and repetitive questions put her at risk for abuse.

Based on interview and record review the facility failed to protect resident's right to privacy. This failure affected two of four residents (R1, R2) reviewed for resident rights on the sample list of four. Findings Include:The facility's Resident Rights Guideline policy dated October 2023 documents the practice of this facility is to provide an environment in which residents may exercise their rights, each day. Residents have certain rights and protections under Federal law and the facility will always protect these rights through care and related services. One example of a resident's rights is Privacy and Confidentiality. R1's Medical Diagnoses List dated August 2025 documents R1 is diagnosed with Schizoaffective Disorder, Bipolar Disorder, Anxiety Disorder, and Insomnia. R1's Minimum Data Set, dated [DATE] documents R1 is cognitively intact. R1's Behavior Tracking for July 2025 through August 2025 documents R1 exhibits behaviors of attention seeking, repetitive questions/statements, invading the personal space of others, pacing, inappropriate comments, false allegations, manipulation, and insomnia. R1 entered other resident's rooms or personal space 17 times in the last 30 days. R1's Care Plan dated 8/14/25 documents R1 exhibits behaviors of attention seeking, repetitive questions/statements, invading the personal space of others, pacing, inappropriate comments, false allegations, manipulation, and insomnia. Staff are to intervene as necessary to protect the rights and safety of others. R2's Medical Diagnoses List dated August 2025 documents R2 is diagnosed with Schizoaffective Disorder, Generalized Anxiety disorder, Depression, Insomnia, and Paranoid Personality Disorder. R2's Care Plan dated 6/6/25 documents R2 is cognitively impaired and has short term memory deficit. R2 requires substantial/dependent assistance with activities of daily living. R2 is incontinent and requires staff to provide perineal care at least every two hours. On 8/17/25 at 2:27 PM V9 Certified Nurses Assistant stated R1 has a lot of anxiety and needs constant attention and reassurance. R1 will follow staff into other resident's rooms and will not listen when you ask her not to do things. R1 will invade other resident's privacy and is hard to redirect. R1will get into staff or resident's faces when asking them repetitive questions. V9 stated R1 will often open the curtain to talk to staff while they are providing personal care for R1's roommate (R2). V9 stated staff will have to stop what they are doing to redirect R1 and she continues to invade R2's privacy. On 8/17/25 at 2:37 PM V7 Licensed Practical Nurse stated R1 is constantly invading others' privacy and personal space. On 8/17/25 at 2:51 PM V6 Licensed Practical Nurse stated R1 bothers other residents and invades their privacy. On 8/17/25 at 4:45 PM V2 Director of Nurses stated she was not aware of R1 continually opening R2's privacy curtain while staff are providing care and confirmed that is a violation of R2's right to privacy.

Based on interview and record review the facility failed to protect the resident's right to be free from physical abuse by another resident with known physical behaviors for two of four residents (R1, R2) reviewed for abuse in the sample list of seven residents. This failure resulted in R2 experiencing physical trauma including a lacerated lip, swollen eye, and multiple scratches, and fear of R1 causing R2 to refuse emergency services due to fear of R1 attacking R2 in the hospital after R1 punched R2 multiple times. This past non-compliance occurred from 7/18/25-7/25/25.R2's Electronic Medical Record (EMR) documents medical diagnoses as Schizoaffective Disorder, Paranoid Personality Disorder, Dementia with Agitation, Extra Pyramidal and movement disorder and Paranoid Schizophrenia. R2's Minimum Data Set (MDS) dated [DATE] documents R2 as cognitively intact. This same MDS documents R2 requires supervision for eating, oral hygiene, toileting, bathing, dressing, personal hygiene, bed mobility, transfers and walking up to 150 feet. R2's Nurse Progress Note dated 7/19/25 at 12:13 AM documents V4 Licensed Practical Nurse (LPN) was in R2's room administering medication to R2's roommate and noted R2 was laying in his bed laughing uncontrollably just prior to this incident. This same note documents A short time later, (R1) heard (R2's) laughter and entered (R2's) room. (R1) was verbally and physically aggressive. This same note documents (V5) Activity Assistant (AA) separated R1 and R2 and then R1 was assisted to R1's room across the hall. This same note states R2 stated R1 yelled at him to stop laughing. This same note documents R1 approached R2's bed where he was laying and hit R2 several times on the head. This same note documents R2 obtained a cut on his top lip and refused to go to the emergency room for medical care. R1's Minimum Data Set (MDS) dated [DATE] documents R1 as cognitively intact. This same MDS documents R1 requires supervision for eating, oral hygiene, toileting, bathing, dressing, personal hygiene, bed mobility, transfers and walking up to 150 feet. R1's Nurse Progress Note dated 7/19/25 documents R1 was walking down the hallway towards his room, as R1 got closer to his room R1's verbally aggressive behavior became louder, then R1 dropped his linens that he was carrying for his shower and R1 entered R2's room. This same note documents (V4) LPN yelled and said NO do not go in there. (V5) Activity Assistant (AA) separated (R1, R2). (V5) AA took (R1) to his room across the hall. (R1) had a bloody nose. When the staff asked what happened (R1) stated (R2) was laughing and (R1) believed that (R2) was laughing at him. R6's Minimum Data Set (MDS) dated [DATE] documents R6 as cognitively intact.R1 and R2's shared Final Incident Report to the State Agency dated 7/24/25 documents R1 believed R2 was laughing at him and entered R2's room where a physical altercation occurred. This same report documents staff were able to break up the altercation. This same report documents R2 obtained a cut to his upper lip and R1 was noted to have a bloody nose. On 8/9/25 at 9:45 AM R2 stated he was relaxing in his bed the night of 7/18/25 when R1 'came storming in my room and beat me up.' R2 stated he did not know why R1 was so mad. R2 stated R1 punched R2 with closed fists in the head, arms and face and repeatedly yelled 'Shut the f*** (expletive) up.' R2 stated he put his arms over his face in order to defend and protect himself. R2 stated R1 pulled him out of his bed onto the floor and continued to hit R2. R2 stated V5 Activity Assistant (AA) entered R2's room and had to 'pull' R1 off of R2. R2 stated I was so frightened that night. I didn't want to leave the room. I didn't want to go to the hospital because that is where (R1) was going. I just stayed in my room because I was afraid. It really hurt when (R1) was punching me. (R1) beat me up one other time on the smoking patio a long time ago. R2 stated V5 AA stayed with R1 until the police arrived to protect R2 from R1 in case R1 came back in R2's room.On 8/9/25 at 2:50 PM R6 stated he witnessed R1 hitting R2. R6 stated R2 was his roommate at the time and he never had any 'trouble' with R2. R6 stated R1 has a bad temper and stays away from R1 as much as possible. R6 stated he was sitting on his bed by the window when R1 'marched' into his room and started punching R2. R6 stated R2 was just laying in his bed and did not provoke R1. R6 stated he felt shocked that anyone would come into his room and just start beating someone up and felt scared of R1. R6 stated he was glad 'they' took R1 away so that R6 didn't have to worry about R1 returning to his room to 'get' R2. On 8/9/25 at 11:30 AM V2 Director of Nurses (DON) confirmed R1 walked into R2's room on 7/18/25 without provocation and hit and punched R2. V2 DON stated R2 has a behavior of laughing hysterically and believes that R1 thought R2 was laughing at R1. V2 DON stated the staff immediately responded when they heard the screaming and yelling coming from R2's room. On 8/9/25 at 1:15 PM V4 LPN stated the evening of 7/18/25 around 8:30-9:00 PM R1 was walking down the hall heading towards his room. V4 LPN stated R1 was carrying his towels and sheets he had gotten from the linen bin. V4 LPN stated R1 was talking loudly to himself and talking to the voices he hears in his head. V4 LPN stated R1 walked by R2's room. V4 LPN stated R2 has a medical disorder where he laughs uncontrollably. V4 LPN stated V4 had just been in R2's room administering medications to R2's roommate. V4 LPN stated R2 was laying in his bed with the blankets pulled up to his chest just prior to R1 entering R2's room. V4 LPN stated R1 walked by R2's room and then turned around, threw all of the linens in the hallway and walked into R2's room. V4 LPN stated at the same time as V4 was walking down the hall, V5 Activity Assistant was entering the hallway to see what all the yelling was about. V4 LPN stated V5 Activity Assistant was the first to arrive to R2's room. V4 LPN stated V5 had to pull R1 off of R2. V4 LPN stated she saw that R2 had a cut over his Right Upper Lip and R1 had blood coming out of the Left side of his nose. V4 LPN stated R1 stated R2 was laughing at him and it made him mad. V4 LPN stated R2 was visibly shaken up, had a shaky voice and stated to V4 'I don't want to leave my room.' V4 LPN stated R1 and R2 have had a previous altercation 'a few years ago' where R1 hit R2 on the smoking patio. On 8/9/25 at 1:40 PM V5 Activity Assistant (AA) stated he was working the evening of 7/18/25. V5 AA stated R1 had been yelling and talking loudly to himself and pacing up and down the hallway that evening. V5 stated R1 thinks he is the president of the United States and hears voices in his head that tell him to do bad things sometimes. V5 AA stated R1 and R2 have had prior history of R1 hitting R2. V5 AA stated R1 and R2 used to be roommates and had to be separated due to R1 hitting R2. V5 AA stated R2 was laying in his bed when R1 'stormed' into R2's room and began hitting R2. V5 AA stated V5 was the first staff member to get to R2's room. V5 AA stated he saw R1 hitting R2, saw R2 had scratches on both of his arms, a cup upper lip, swollen eye and R1 had a bloody nose. V5 AA stated R1 and R2 were separated. V5 AA stated R1 told V5 that R2 was laughing at R1 and it made him mad. V5 AA stated R2 was very visibly shaken up. The undated facility policy titled Abuse Prevention Policy documents the residents have the right to be free from abuse, neglect, exploitation, misappropriate of property, deprivation of goods and services by staff or mistreatment. This facility prohibits abuse, neglect, exploitation, misappropriate of property and mistreatment of residents. Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish to a resident. Physical abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention. Physical abuse includes hitting, slapping, pinching, kicking and controlling behavior through corporal punishment. Prior to the survey date of 8/10/25, the facility had taken the following actions to correct the noncompliance: 1. The Quality Assurance Performance Improvement (QAPI) team including V1 Administrator, V15 [NAME] President of Operations (VPO) and V16 Regional Clinical Nurse (RCN) met on 7/22/25 to identify opportunities for improvement/deficient practice. 2. Immediate action consisted of: R1 and R2 were immediately separated. R1 was sent to the emergency room for evaluation and returned on continual monitoring (1:1) supervision. This continual monitoring was in place until R1 could be seen by psychiatry at which time, R1 was placed on 15 minute visual checks which have remained in place. 3. Actions completed and/or ongoing by 7/25/25: All staff were in serviced on behavioral intervention resources prior to the next shift; All behavioral care plans were reviewed to ensure interventions were in place; All Gradual Dose Reduction (GDR) requests and increases in behaviors within the last three months were reviewed; Behavioral Tracking and GDR audits were scheduled for three times the first week, twice the second week and then weekly for four weeks and were initiated and ongoing and; Resident care plans will be audited weekly for four weeks to ensure timely behavioral interventions are appropriate and effective with behavior tracking in place. Staff in-service on ‘Different ways to deescalate behaviors and put interventions in place' was completed on 7/25/25. Care plans and GDRs were reviewed by V1 Administrator, V2 DON and V16 Regional Clinical Nurse. Behavioral care plans and GDR audits were initiated on 7/22/25 and completed on 7/25/25. 4. V1 Administrator will report the findings to the QAPI meeting quarterly. V1 Administrator stated the facility has not had the next QAPI meeting but thus far there have been no new substantiated instances of abuse since 7/18/25.

Based on interview and record review the facility failed to ensure resident dignity for three of three residents (R4, R5, R6) reviewed for dignity in a sample list of seven residents.R4's Minimum Data Set (MDS) dated [DATE] documents R4 as cognitively intact. This same MDS documents R4 requires supervision with eating, oral hygiene, toileting, bathing, dressing, personal hygiene and bed mobility. R4's Care plan documents medical diagnoses as Thoracic Scoliosis, Depression, Neuropathy, Thrombophlebitis of Lower Extremities, Unsteady on Feet, Muscle Wasting and Atrophy and Major Depressive disorder. This same care plan initiated 11/8/24 does not document a focus area, goal nor interventions for R4's behaviors of consensual sexual behavior with male peers prior to 7/29/25. This same care plan documents R4 requires a wheelchair for mobility. R5's Minimum Data Set (MDS) dated [DATE] documents R5 as cognitively intact. R6's Minimum Data Set (MDS) dated [DATE] documents R6 as cognitively intact. R4 and R5's shared Final Report to the State Agency dated 8/1/25 documents R4 stated R5 started rubbing her upper leg then moved up to touch her perineal area while she was sitting in the day room. This same report documents R4 moved away from R5 and that R5 did not actually touch R4's perineal area. R4's written statement dated 7/29/25 documents (R4) was sitting next to the ping pong table. (R5) got up off the couch and came towards me. (R5) was standing and bent down and started rubbing my leg. (R5) started at the knee moving up towards my (points to vagina). I backed away from (R5) and went to my room. I don't know what (R5) was thinking. On 8/9/25 at 12:10 PM V7 Licensed Practical Nurse (LPN) stated R5 touched R4 inappropriately in the hall next to the dayroom on the South unit on 7/29/25. V7 LPN stated R5 walked up to R4 who requires a wheelchair and touched R4's upper thigh and then moved his hand farther towards R4's genital area then R4 wheeled herself back away from R5. V7 LPN stated R4 told V7 that ‘(R5) touched my leg and tried to reach my vagina. I didn't like that.' V7 LPN stated R5 was sent to the emergency room for evaluation due to his behaviors. On 8/9/25 at 2:55 PM R6 stated R4 was sitting in the resident lounge in her wheelchair when R5 got up off of the couch (in the same room) and walked over to R4. R6 stated R5 put his hand on the inside of R4's lower thigh/knee area and squeezed lightly and then left his hand there for a few minutes. R6 stated R5 then moved his hand ‘clear up there' (R6 motioned to his perineal area). R6 stated he couldn't believe what he was seeing. R6 stated he was in shock. R6 stated he saw R4 move her wheelchair back away from R5. R6 stated he did not think R5 made contact with R4's perineal area but that ‘it wasn't for lack of trying.' On 8/10/25 at 10:00 AM V1 Administrator stated R4 and R5 both reside on a locked psychiatric unit. V1 Administrator stated both R4 and R5 are cognitively intact yet unable to make decisions for themselves and require constant supervision. V1 Administrator stated she thinks this incident is more of a resident rights issue than abuse due to R5 did not make contact with R4's perineal area. The facility policy titled Resident Rights Guideline revised October 2023 documents residents have the right to be treated with dignity and respect.

Based on observation, interview and record review the facility failed to use a gait belt during a resident's transfer and ambulation to prevent a fall for one (R40)of three residents reviewed for falls in the sample list of 44. The fall resulted in R40 sustaining a skin tear in the right arm. Findings include: The facility's Fall Prevention policy with a revised date of 11/10/18 documents, Policy: To provide for resident safety and to minimize injuries related to falls; decreases falls and still honor each resident's wishes/desires for maximum independence and mobility. Fall Prevention Interventions: 11. Transfer with proper number of assist and gait belt. R40's Fall Risk assessment dated [DATE] documents R40 is at risk for falls. The next Fall Risk Assessment was not completed until 9/27/23 which documents R40 is not at risk for falls even though R40 had falls on 9/6/23 and 9/27/23. On 10/2/23 at 11:00 AM, R40 was in R40's room in R40's wheelchair watching television. R40 stated that R40 fell in R40's room and hurt R40's back when R40 fell . R40's Nurse Progress notes dated 9/6/23 at 2:30 PM documents R40 fell in R40's room. This note documents R40 was in R40's wheelchair and stood up to try to hang up a sweater in the closet and R40's knees gave out and R40 fell . R40 sustained a skin tear to the right arm. The intervention developed for this fall was to educate R40 to ask for assistance. R40's Nurse Progress notes dated 9/27/23 at 5:42 AM documents at 4:30 AM, R40 lost R40's balance walking to the bathroom. This note documents V14 Certified Nursing Assistant (CNA) was with R40 but could not catch R40 because the privacy curtain got in the way. This note documents R40 complained of back pain, ambulance called and R40 transported to the hospital. R40's Minimum Data Set (MDS) dated [DATE] documents R40 requires extensive assistance of two staff for transfers and is not steady walking and moving from a seated to standing position. R40's Care Plan with a revision dated of 6/21/23 documents R40 had an actual fall with interventions to educate to ask for assistance dated 8/28/23 and to sit on the side of the bed until dizziness subsides dated 9/27/23. On 10/4/23 at 11:05 AM, V2 Director of Nursing stated that R40 should be walked with a gait belt and assistance of at least one staff member. V2 stated V2 does not know if R40 had a gait belt on during the fall on 9/27/23. On 10/4/23 at 1:51 PM, V14 CNA stated that V14 did not have a gait belt on R40 when R40 fell . V14 stated that R40 had gotten R40's self out of bed and had started walking to the bathroom when V14 came in R40's room. V14 stated V14 went to help R40 but did not put a gait belt on R40 and R40 lost R40's balance and V14 could not catch R40. V14 stated that R40 complained of back pain and the nurse assessed R40 and sent R40 to the emergency room . On 10/4/23 at 1:59 PM, V13 R40's Physician confirmed there was a fracture of the T12 vertebrae but it could not be determined if it was a new fracture or an old fracture. V13 stated that since R40 was not in excruciating pain and is back to R40's baseline it was most likely an old fracture that was irritated by the fall.

Based on interview and record review the facility failed to transfer a sleeping resident from her wheelchair to her bed, which resulted in a fall and subsequent injury for one cognitively impaired resident (R1). R1 was sent to the emergency room , seen, and treated for a forehead laceration and right and left nasal bone fractures after falling at the facility on 8/27/22. R1 is one of three residents reviewed for falls in the sample of three. Findings include: R1's Physician Order Sheet (POS) dated September 2022 documents R1 is diagnosed with Dementia, Anxiety, Depression, Behavioral Disturbances with [CONDITION(S)], Altered Mental Status, and [CONDITION(S)]-like Activity. R1's Minimum Data Set (MDS) dated [DATE] documents R1 is severely cognitively impaired. R1's Care Plan dated 8/18/22 documents R1 is at high risk for self injury as evidence by previous falls with injuries, declining cognitive status, and resistance to wait for staff assistance with transfers. R1's Final Report: Fall with Injury dated 9/2/22 documents R1 fell on [DATE] at 3:00 PM. R1 was sitting in her wheelchair at the nurses' station. Nurses were giving report and conducting narcotic medication count when they heard R1's chair alarm sound and looked over to see her lying on the floor with blood coming from the right side of her forehead and bridge of her nose. Prior to the fall R1 was observed sitting in her wheelchair sleeping in an upright position with her head tilted back. R1 was sent to the emergency room . R1 was diagnosed with a forehead laceration and nasal bone fractures. R1's Maxillofacial Computed Tomography (CT) Scan Report dated 8/27/22 documents R1 fell at the facility and sustained right and left nasal bone fractures and rightward deviation of the nose. On 9/21/22 at 2:00 PM V3 Licensed Practical Nurse stated she had just given report and started counting the narcotic medications. R1 was sleeping in her wheelchair by the nurses station. R1 is confused, a high fall risk, and never asks for help with transfers. R1 had her head tilted back while sitting upright in her wheelchair and she was zonked. V3 stated she did not ask staff to put her in her bed when she noticed her sleeping. A few minutes later, R1's chair alarm went off and V3 looked over and saw R1 lying face down on the floor, in front of her wheelchair. R1 had tipped forward while sleeping and fell on to her face. R1 had hit her nose and head on the floor. She had a laceration to her forehead. Staff sent her to the emergency room and R1 had nasal bone fractures. On 9/22/22 at 10:05 AM V8 Certified Nurses Assistant (CNA) stated R1's sleep pattern is very messed up. She often won't sleep at night and will fall asleep during the day. She will fall asleep in her wheelchair and often leans to one side. If she falls asleep in her chair staff are supposed to lay her in her bed. On 9/22/22 at 10:50 AM V2 Director of Nurses confirmed R1 is a high fall risk. She has had previous falls. She is confused. She does not know her limits. She does not call for help. She has a very erratic sleep pattern and will often stay awake all night and fall asleep during the day. She will fall asleep in her chair and if she does, staff are to put her in her bed. If she falls asleep in her chair she often leans to one side or another and could easily fall out. V2 DON confirmed when R1 fell asleep in her wheelchair, staff should have laid her down in her bed. On 9/22/22 at 11:48 AM V9 Medical Director stated R1 is a very high fall risk while she is awake, asleep, in bed, and in wheelchair. R1 does not know her own limits and she does not call for help. V9 stated if R1 fell asleep in her wheelchair, then staff should have laid her down in her bed. V9 confirmed it wouldn't be safe to sleep sitting upright in a regular wheelchair and if R1 had been laid down, she would not have fallen out of the chair while sleeping. The Fall Prevention policy dated 11/10/18 documents the policy serves to provide resident safety and minimize injuries related to falls. All staff must observe residents for safety.

Based on observation, record review, and interview the facility failed to maintain a resident's ambulatory status after being discharged from physical therapy by failing to implement a restorative program for one of three residents (R20) reviewed for restorative programs in the sample of 17. This failure resulted in R20 losing the ability to ambulate and requiring mechanical lifting assistance at times for transfers. Findings include: The Physicians Order Sheet (POS) dated 11/01/2014 through 11/30/2014 documents an order for [REDACTED]. The PT (physical therapy) - Therapist Progress & Discharge Summary dated 09/26/2014 documents that R20 received PT services from 08/21/2014 to 09/26/2014. It also documents that R20 ambulates 25 feet safely with front wheeled walker and contact guard assist on even surfaces. The Therapy Discharge Notice dated 09/26/2014 documents instructions for R20 to participate in a restorative rehabilitation program for range of motion, transfers, walk to dine, and eating. The ADL (Activities of Daily Living) Flow Record dated August 2014 documents that R20 ambulates with one person assistance. The ADL (Activities of Daily Living) Flow Record dated November 2014 documents that R20 does not ambulate. The Physical Restraint/Enabler assessment dated [DATE] documents that R20 does not ambulate. It also documents that R20 requires use of a soft cushion restraint while up in the wheelchair due to R20 leaning to either side. On 11/18/14 at 2:00 p.m. E9 and E10 removed R20's soft cushion restraint from his wheel chair and then used a gait belt to assist R20 to stand from his wheel chair. Then, after being prompted, R20 moved his feet slightly in order to pivot and E9 and E10 assisted R20 to transfer to his bed. E9 then lifted R20's legs onto bed while E10 turned R20's torso to a lying position. On 11/18/14 at 9:40 a.m. E11 Licensed Practical Nurse (L.P.N.)/Restorative Nurse confirmed that R20 was discharged from therapy on 09/26/14 with instructions to participate in a restorative program. At that time E11 stated that she has not had time to initiate R20's restorative program. E11 explained that other residents were a higher priority. At that time E11 confirmed that R20 can not ambulate and requires the assistance of two staff members to transfer. E11 also confirmed that R20 requires the use of a soft cushion restraint for positioning when he is in his wheel chair because he leans to one side and forward when sitting. On 11/18/14 at 10:35 a.m. E12 Physical Therapist stated that R20 should have received restorative programming after R20 was discharged from therapy. E12 confirmed that R20 could walk 25 feet with contact guard assist when he was discharged from therapy on 09/26/14. On 11/18/14 at 2:30 p.m. E9 stated that R20 could walk approximately 25 to 30 feet when R20 was receiving therapy. E9 also stated that R20 has not ambulated since therapy discharged him (on 9/26/14). E9 stated that R20 requires two assist for transfers. E10 stated, "no one told me to walk (R20)". E10 confirmed that R20 does not receive restorative programming. On 11/18/14 at 3:10 p.m. E2 Director of Nurses stated that restorative programming would have helped R20 maintain his functional status. E2 also stated that she was not aware of a medical condition that caused R20's decline. E2 stated that R20's restorative programming should have been started.

A. Based on interview and record review the facility failed to evaluate the effectiveness of interventions following several falls and failed to implement revised interventions to prevent additional falls for one of four residents (R13) reviewed for falls in the sample of 16. R13's fell , sustaining a laceration and a closed head injury. Findings include: The physician's orders [REDACTED]. The Minimum Data Set ((MDS) dated [DATE] states R13 requires supervision of staff for ambulation and R13's balance is unsteady with impairment of lower extremities on both sides. The facility's form titled "Resident Fall Tracking Log" for the month of May 2011 indicates that R13 had two falls on 5/10/11 at 5 PM and 10:30 PM and one fall on 5/11/11 at 6:30 AM. The facility's "Investigation Report For Falls" dated 5/10/11 at 5 PM states that R13 had an unwitnessed fall where R13 was trying to reach his oxygen tank on his chair and was found lying on his right side in the fetal position. The form states under the section titled "What new intervention has been implemented to prevent another fall?"-- "Tripped - Acute condition, just returned from the hospital: Pneumonia, COPD, UTI (urinary tract infection) ." The "Investigation Report For Falls" dated 5/11/11 for the fall R13 had on 5/10/11 at 10:30 PM states R13 had an unwitnessed fall where R13 was messing with the oxygen machine and fell hitting his head on the oxygen concentrator. R13 was found on the floor. The section of the form titled "Root Cause Analysis" states "Acute condition, just returned from hospital with pneumonia." The section titled "What new intervention was implemented to prevent any further falls" states "Patient Education." The "Investigation Report For Falls" dated 5/11/11 for the 6:30 AM fall states that R13 had an unwitnessed fall where he was trying to get up, was found lying on the floor on right side beside the bed. The section titled "Root Cause Analysis" states "(R13) very weak from hospital stay. Acute condition, sent to emergency room for Medical ." Section titled "What new intervention was implemented to prevent any further falls?" states "Hospital" R13's Nurses Notes dated 5/11/11 at 6:30 AM states " (R13) is on the floor beside bed mostly lying on right side, had blood dripping from laceration above right brow...complains head, right knee and middle finger on left hand hurting...." emergency room Report dated 5/11/11 states that R13 had right frontal scalp hematoma, received two sutures to the laceration and was admitted to the hospital with [REDACTED]. E2, DON (Director of Nurses) on 11/18/11 at 3:05 PM stated that no new interventions were implemented after the falls and on the third fall "we sent him to the hospital for evaluation." R13's care plan dated 8/30/11 did not show any new interventions for the two falls sustained on 5/10/11 or the fall on 5/11/11. B. Based on observation and interview, the facility failed to ensure that toilet grab bars were secure and safe; failed to ensure that the two toilets were secured to floor; and failed to ensure that the metal defector shield on the hot water base broad heat radiator was secure with no exposed sharp edges. These failures potentially affect 13 of 13 North side male residents (R2, R8, R13, R15, R51, R52, R53, R54, R55, R56, R57, R58, and R59) and 25 of 25 South side male residents (R10, R27, R28, R29, R30, R31, R32, R33, R34, R35, R36, R37, R38, R39, R40, R41, R42, R43, R44, R45, R46, R47, R48, R49, and R50). Findings include: 1. During General Observation tour on 11-16-11 at 9:30 A.M. accompanied by the Maintenance Director, E5 and the Housekeeping Director, E6, the grab bars attached to the toilet seat in the North side Men's toilet room were loose and wobbly. This toilet is accessible to 13 of 13 residents (R2, R8, R13, R15, R51, R52, R53, R54, R55, R56, R57, R58, and R59). 2. During General Observation tour on 11-16-11 at 10:30 A.M., the two toilets in South side Men's shower room were loose, wobbly, and easily moveable. The toilets were not attached firmly to the floor. The toilets are accessible to 25 of 25 residents (R10, R27, R28, R29, R30, R31, R32, R33, R34, R35, R36, R37, R38, R39, R40, R41, R42, R43, R44, R45, R46, R47, R48, R49, and R50). E5 stated at time of observation "there are big boys over here." 3. During General Observation tour on 11-16-11 at 10:35 A.M., the metal defector shield for the hot water heat base broad radiator outside of the South side Medication room (located in the resident dining room) was hanging loose. The shield had exposed sharp edges that could injury a resident.